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Carpal Tunnel Syndrome – Are There Other Tunnels?, by the Active Release certified doctors at Denver Chiropractic Center

Carpal Tunnel Syndrome – Are There Other Tunnels?

Carpal Tunnel Syndrome (CTS) refers to the median nerve being pinched in a tunnel at the wrist. As the name implies, “carpal” refers to the 8 small bones in the wrist that make up the “U” shaped part of the tunnel and “syndrome” means symptoms that are specific and unique to this condition. As we learned last month, CTS can be affected by nerve pinches more proximal to the wrist, such as at the forearm, elbow, mid-upper arm, shoulder or neck.

To make matters more complex, there are two other nerves in the arm that can also be pinched in different tunnels, and the symptoms of numbing and tingling in the arm and hand occur with those conditions as well. This is why a careful clinical history, examination, and sometimes special tests like an EMG/NCV (electromyogram/nerve conduction velocity) offer the information that allows for an accurate diagnosis of one or more of these “tunnel syndromes” in the “CTS” patient. Let’s look at these different tunnels and their associated symptoms, as this will help you understand the ways we can differentiate between these various syndromes or conditions.

Let’s start at the neck. There are seven cervical vertebrae and eight cervical spinal nerves that exit the spine through a small hole called the IVF (intervertebral foramen). Each nerve, like a wire to a light, goes specifically to a known location which includes: the head (nerves C1, 2, 3), the neck and shoulders (C4, 5), the thumb side of the arm (C6), the middle hand and finger (C7) and the pinky side of the lower arm and hand (C8). If a nerve gets pinched at the spinal level (such as a herniated disk in the neck), usually there is numbness, tingling, and/or pain and sometimes, usually a little later, weakness in the affected part/s of the arm and hand (or numbness in the scalp if it’s a C1-3 nerve pinch).

So, we can test the patient’s sensation using light touch, pin prick, vibration, and/or 2-points brought progressively closer together until 1-point is perceived and then comparing it to the other arm/hand. Reflexes and muscle strength are also tested to see if the motor part of the nerve is involved in the pinch. The exam includes compression tests of the neck to see if the arm “lights up” with symptoms during the test.

Next is the shoulder. Here, the nerves and blood vessels travel through an opening between the collar bone, 1st rib and the chest muscles (Pectorals). As you might think, the nerves and blood vessels can be stretched and pinched as they travel through this opening and can cause “thoracic outlet syndrome.” Symptoms occur when we raise the arm overhead.

Hence, our tests include checking the pulse at the wrist to see if it reduces or lessens in intensity as we raise the arm over the head. At the shoulder, the ulnar nerve is the most commonly pinched nerve, which will make the pinky side of the arm and hand numb, tingly, and/or painful. A less common place to pinch the nerves is along humerus bone (upper arm) by a bony process and ligament that is usually not there or resulting from a fracture. Here, an x-ray will show the problem.

The elbow is the MOST common place to trap the ulnar nerve in the “cubital tunnel” located at the inner elbow near the “funny bone” which we have all bumped more than once. Cubital tunnel syndrome affects the pinky side of the hand from the elbow down. The median/carpal tunnel nerve can get trapped here by the pronator teres muscle, thus “pronator tunnel syndrome.” This COMMONLY accompanies CTS and MUST be treated to obtain good results with CTS patients. The radial nerve can be trapped at the radial tunnel located on the outside of the elbow and creates thumb side and back of the hand numbness/tingling.

Any or all of these nerve can get “trapped” by the muscles that run near them. This is where Active Release Techniques (ART) treatment separates itself for other modalities. ART is the only system that trains providers how to check these entrapment spots muscle by muscle. Once identified, the trained and certified ART provider knows how to release the muscles and remove the pressure. This goes way beyond standard chiropractic treatment or basic physical therapy.

So now you see the importance of evaluating and treating ALL the tunnels when CTS is present so a thorough job is done (which is what we do at Denver Chiropractic Center). Try the LEAST invasive approach first – non-surgical treatment – as it’s usually all that is needed!

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Low Back Pain and Balance

Statistically, most people (estimated to be about 90%) will seek care for Low Back Pain (LBP) at some point in their lifetime. Last month, we discussed the role foot orthotics play in the management of LBP by improving balance, and it seems appropriate to discuss other ways we can improve our balance, hence the topic this month!

Balance is a skill that is learned as we develop. Initially, as infants, we have not developed the “neuromotor pathways” or, sequence of signals between the brain and our toes, feet, ankles, knees, hips, and so on. The constant flow of sensory information received and processed by the brain prompts motor messages to be sent back to our limbs and allows us to move in a progressively more coordinated manner as we develop.

This natural progression of developing motor control starts with crude, rather uncontrolled movement of the fingers, hands, arms, legs, and feet, and soon, we learn to hold up our head, scoot, roll over, crawl, stand, and eventually walk (usually during the first 12 months of life). The learning process of recognizing sounds, voice quality and inflections, and words occurs simultaneously.

This bombardment of sensory information to the brain leads to the ability to gradually perform highly integrated functions including walking, running, jumping, and dancing. As part of that learning process, falling frequently occurs. We all recall the challenges of learning how to ride a bike, swim, do a somersault, climb a tree, swing, dance, do gymnastics, ski, and on and on. As time passes and we enter middle age, we become more sedentary.

As a result, we start losing our “proprioceptive edge” and become less steady, leading to more frequent balance loss and falls. Eventually, we have to hold on to hand railings or the wall in order to keep our balance and falling occurs more frequently. Couple this gradual loss of balance with bone demineralization (osteoporosis) and the risk of a fracture, such as a hip or vertebra, increases as well.

So the question arises, what can we do to slow down this process and maybe even reverse it? The answer is, A LOT!!! Just like muscles shrink and atrophy if they are not used, so does our ability to maintain our balance. We have to keep challenging our balance in order to keep those neuromotor pathways open. That need doesn’t stop after childhood, and in fact, becomes more important as we age. Last month, we talked about the “normal” length of time people can stand on one foot with the eyes open verses closed.

If you tried the test, do you remember the steadiness difference? This “test” can be used at various time intervals, such as once a month, as you add balance challenging exercises to your daily routine. Frequently, people will find that within the first 2-4 weeks, they will feel more “sure” or secure on their feet, and even may not feel the need for a cane, or they’ll reach out less often for a hand rail. Start with simple exercises like standing with your feet together and hold that position for progressively longer times (eyes open and closed). We will continue this discussion next month with more balance stimulating exercises.

This week’s 1-page health news…

Dr. Stripling is back this week showing you how to stretch those hamstrings out. Video link is at the bottom of this page.

Mental Attitude: Multiple Media Use. Media use among United States youth has increased 20% in the past decade, and the amount of time spent multitasking with media has spiked 120%. Using multiple forms of media at the same time (ie. playing a computer game while watching TV) has been linked to symptoms of anxiety and depression.
Cyberpsychology, Behavior and Social Networking, December 2012

Diet: Rice Bran. The bioactive components in rice bran show anti-cancer activity, including the ability to inhibit cell proliferation, alter cell cycle progression, and initiate the programmed cell death (known as apoptosis) in malignant cells. Bioactive components of rice bran act not only within cancer cells but around the cells to create conditions in the surrounding tissues that promote the function of healthy cells while inhibiting the function of cancer cells. This tissue microenvironment activity includes controlling chronic inflammation, often a precursor for cancer. Rice bran may also promote an anti-cancer immune response and protect against cancer. Advances in Nutrition, December 2012

Exercise: Want A Healthy Brain? Physical exercise is important when it comes to maintaining a healthy brain. Scientists found that Growth Hormone (stimulated by exercise) increases the amount of stem cells that actively generate new nerve cells in the brain. Growth Hormone also slows and can even reverse the decline in new nerve cell formation normally seen as our bodies age. University of Queensland, November 2012

Chiropractic: Bone Spurs? Bone spurs (osteophytes) are bony projections that form off of bones in and along joints, and are often seen with arthritis. Bone spurs can limit joint motion and can cause joint pain. Bone spurs form when the body tries to increase the surface area of the joint to better distribute weight across a joint surface that has been damaged by arthritis. To slow formation and alleviate symptoms, it has been shown that joint motion improves nutrition to the tissue and maintains the health of the joint. Spine, 1977 In our opinion, Active Release Techniques soft tissue work combined with spinal adjusting is the best way to restore or maintain joint mobility.

Wellness/Prevention: Sleep and Insulin Resistance. High levels of insulin resistance can lead to the development of diabetes. Teenagers who normally sleep six hours a night can improve insulin resistance by 9% by simply sleeping one additional hour. This probably extrapolates to adults as well Sleep, October 2012

Quote: “He who has health, has hope; and he who has hope, has everything.” ~ Thomas Carlyle

Dr. Glenn Hyman’s Crossfit Gym & this week’s 1-Page Health News

People are always asking me (Glenn) where I workout. Meredith and I train using a blend of Crossfit and Crossfit Endurance in exactly 91 sq ft of our basement (plus the outside stuff of course). You’d be surprised how much you can do in 91 sq ft with kettlebells, a barbell bumper set, a pull up bar and some imagination. (Secret hint for our loyal blog readers- Stay tuned for an upcoming announcement regarding Crossfit, Dr. Stripling & myself – it’s gonna be a biggie!) Anyway, here’s my present Cossfit Gym:

Speaking of Dr. Stripling, his popular video series is back this week. This time around, Dr. Stripling shows you some quick and easy self-help strategies for the low back.The  link is at the bottom of this email.

Health Alert: Childhood Obesity Rates Falling! During the first decade of the 21st century, childhood obesity rates among children in lower income families in the United States have decreased (14.94% in 2010 vs. 15.21% in 2003). The Journal of the American Medical Association, December 2012

Diet: Red Wine and Cancer. Resveratrol, a chemical found in red wine, is thought to help prevent cancer. Lab models designed to identify any benefits from consuming the amount of resveratrol in 2 daily glasses of wine found a reduction in the rate of bowel tumors by around 50%.(Note-Yay!) University of Leicester, December 2012

Exercise: Good Vibrations. Within 7 months of starting a poor diet, normal mice became obese, with significant damage to their immune and skeletal systems. Daily 15-minute treatments of low-intensity vibration, barely perceptible to human touch, helped restore the immune and skeletal systems of the mice towards those of mice fed a regular diet. If this effect translates to humans, it could have benefits for obese people suffering from immune problems related to their obesity. The FASEB Journal, December 2012

Chiropractic: Quit Smoking! Smokers suffering from spinal disorders and related back pain reported greater discomfort than those who stopped smoking during an 8 month treatment period. Patients who had never smoked and prior smokers reported significantly less back pain than current smokers and those who had quit smoking during their care. Journal of Bone and Joint Surgery, December 2012

Wellness/Prevention: Sleep and Pain? In a recent study, participants who slept 1.8 hours more per night had increased daytime alertness and less pain sensitivity than those who slept their normal amount. Sleep, December 2012

Quote: “What is called genius is the abundance of life and health.” ~ Henry David Thoreau

Fibromyalgia and Neurotransmission

Neurotransmission is the method by which nerves “speak” to each other so impulses can be sent from one part of your body to the brain and back. For example, when you touch a hot plate by accident, it doesn’t take long before you quickly let go of the plate. The reason you let go quickly is because of neurotransmission. Certain types of neurons or nerves (called afferents) bring information to the central nervous system where the information is processed and then signals are transferred back to the target site (such as your hand touching the hot plate) by different nerves (called efferents) telling you to immediately let go of that hot object.

It’s like the flow of traffic into a city during rush hour. People work all day and then drive in the opposite direction on their way home (afferents in the morning going in the city or “brain” and efferents in the evening bringing new information home). This “give and take” process of information coming in, being processed and going out helps coordinate our bodily functions. This allows us to constantly adapt to surrounding changes in temperature, stress, noise, and so on.

Each neuron has as many as 1500 connections from other neurons, but they don’t actually touch one another. Rather, there are “synapses” where nerve impulses stimulate the release of calcium and neurotransmitters, which either inhibit or excite another neuron and each neuron may be connected to many other neurons. If the total excitatory stimuli are greater than the inhibitory stimuli, that neuron will “fire” and create a new connection resulting in an action (like dropping the hot plate).

Okay, sorry for the enthusiastic description and details of neurotransmission. More importantly, how does all this relate to fibromyalgia? A new study (published May 14, 2012 in NATURE by scientists at Weill Cornell Medical College) discovered that a single protein (alpha 2 delta), “…exerts a spigot-like function controlling the volume of neurotransmitters and other chemicals that flow between the synapses of brain neurons.” This study shows how brain cells “talk to each other” through these synapses relaying feelings, thoughts, and actions and how this powerful protein plays a crucial role in regulating effective communication in the brain. They found that if they added or decreased this single protein (alpha 2 delta), then the speed of neurotransmission increased or decreased by opening or closing the calcium channels that trigger neurotransmission release.

The relationship between calcium and neurotransmission has been known for 50 years, but how to “turn on or off” the volume is a new discovery. They hope this finding will help in the design of new medications that will help regulate the neurotransmission in the brain, thus help reduce the increased pain perception found in people suffering from fibromyalgia.

Our aim in sharing this information with you is to keep you informed with what is on the cutting edge of research as we’ve said many times before, a “team” of health care provision is the BEST way to manage FM including chiropractic and primary care!